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Case Study of the Month: |
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Cholelithiasis & Post-Hepatic Obstruction In A Dog.
By Dr. Johanna Frank (DACVIM) of New Jersey Mobile Associates |
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History (Vaquez RVT/Frank DVM, DACVIM): An 8-year-old FS Cavalier King Charles Spaniel presented for anorexia for 3 days, decreased drinking, and lethargy. There was prior history of foreign body removal and cholecystectomy owing to cholelithiasis four months earlier. The owner reported that the patient never fully recovered from foreign body surgery and has demonstrated intermittent G.I. signs ever since. Physical examination revealed marked icterus, mucous membranes pale pink with icterus and a CRT<2 sec, mildly enlarged submandibular lymph nodes and 4% dehydration. The patient was admitted for I.V. fluid therapy, supportive care, and further diagnostics. Blood chemistry revealed hyperphosphatemia, high ALT, hyperamylasemia, elevated BUN, increased cholesterol, hyperglobulinemia, marked hyperlipasemia, marked hyperbilirubinemia, and hypokalemia. CBC found leukocytosis, monocytosis, anemia (decreased HCT and RBC) and thrombocytosis. The dog was initially treated with gastroprotectants, steroids, anti-diarrheal medication, and antibiotics. After 24 hours of fluid therapy, the PCV was 17% with a total protein of 8.0 mg/dl with no evidence of autoagglutination. At that point, the dog was QAR with persistent diarrhea but no vomiting or nausea.
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Sonographic Differential Diagnosis (Frank DVM, DACVIM): Hemolytic anemia, biliary obstruction due to a cholelith in the bile duct or a papillary mass at the duodenal papilla, cholangiohepatitis, severe pancreatitis with extra-hepatic bile duct obstruction and neoplasia.
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Sonographic Interpretation (Lindquist DMV, DABVP): Strongly shadowing calculi are present that the duodenal papilla and within the common bile duct (CBD) causing marked dilation (0.97 cm) and post-hepatic obstruction. Periductile hyperechoic fat and adhesions are also present suggestive for friability and inflammation of the double walled duct (CBD). Power flow Doppler demonstrates positive flow in the portal vein (PV) dorsal to the duct and lack of uptake within the common bile duct.
Diagnosis (Lindquist DMV DABVP): Post-hepatic obstruction of the common bile duct with associated cholangitis and surrounding omental/pancreatic inflammation.
Outcome (Vaquez RVT/Frank DVM, DACVIM): Due to the degree of biliary obstruction, the marked elevation in bilirubin and severity of the icterus, surgical referral to a Board Certified surgeon was advised to remove the biliary calculi, clear out bile duct, with possible transposition of the bile duct if needed. The prognosis was guarded and owners elected to euthanize the patient. |
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